The PA DUI ASSOCIATION believes that together we can combat the deadly consequences of DUI. We ask for your support in achieving this goal. Please complete this application and return it with the indicated dues.

MEMBERSHIP APPLICATION

NAME & TITLE ________________________

ORGANIZATION _______________________
____________________________________

ADDRESS ___________________________
____________________________________

CITY ________________________________

STATE ______ ZIP _____________________

TELEPHONE () _____________________

MEMBERSHIPS

INDIVIDUAL
New - $45
Renewal - $35
Student/Senior - $15

Please return to:

 ORGANIZATIONAL
Corporate - $250
Program - $500

PA DUI ASSOCIATION
2413 N. Front St.
Harrisburg, PA 17110
(717) 238-4354 / 1-800-627-2384

Print out and mail with dues